Sunday, February 6, 2011

Coping with Both/And

Image via WikipediaWant to know what the hardest thing is about family medicine -- for me, that is? Explaining to family doctors why I want to be something else. And doing so in a way that doesn't hurt anyone's feelings or give the impression I'm not interested in medicine. Trust me, this is no mean task, especially when doing a family or internal medicine rotation. You see, as a student, I want to get the best education I can. But this tends to create confusion because, somewhere along the line, psychiatry has gotten the reputation of being the discipline for those who don't have the hots for medicine. Making it tricky for those of us who do.

Like most generalizations, this one doesn't hold true in every case. Still, it holds true in enough of them that it becomes necessary for the rest of us to try to overcome the stereotype. But here's the rub: if I act motivated to learn physical medicine, it calls my commitment to psychiatry into question. If I act like all I'm interested in is psychiatry, then I may not be taken as seriously as the student who identifies with Marcus Welby, Ben Casey, Doug Ross, or Alex Karey, MD or DO, depending on which generation of television doctors you follow. Damned if I do and damned if I don't.

To be fair, I'm sure it must be the same for students whose stated intention of becoming "doctors" is complicated by an interest in patients' psychiatric conditions. Both/and isn't the easiest thing to cope with on the best of days. Now, it's entirely possible that those appear medically-ambivalent might actually be happier with advanced degrees in psychology. I don't know, I'm just saying. You can definitely count on medicine involving you with patients in ways you don't have to think about as a psychologist.

Take this past Thursday, for example. The only other time I've performed a male (why do we call it that? I mean, is there any other kind?) prostate exam was in lab one evening a little over a year ago. On the same occasion, I did my first female breast and uterine exam, both with actor-patients to whom and for whom I will be eternally grateful. As you may know first-hand, exams like these are a very intimate, for doctors and patients alike. And they're things a psychologist doesn't ever do.

It's true, psychiatrists don't routinely do prostate exams or pap smears, but that's not the point. They receive this kind of training because they're in training to become doctors and therefore, approach the brain-mind-behavior interface from the standpoint of one who practices medicine, not psychology. As an aside, this is one of my objections to allowing psychologists to prescribe psychoactive medications, but that's for another day. Call me narrow-minded, but I don't think one can be a competent psychiatrist without being a competent physician for the very reason that psychiatry is the medical discipline whose task is to tread the no-man's land between mind and body.

St. Augustine, Bishop of Hippo (not of hippopotamuses, though I certainly have no objection to the idea -- ever attend a blessing of the animals on the Feast of St. Francis of Assisi?) in Northern Africa during the fourth century, prayed, "God, deliver me from the need to justify myself." I guess I'm not there, yet, but God knows my heart and I think my preceptor in rural Maine does as well, because he surely gives my desire to learn physical medicine the same attention he does my interest in psychiatry. It's just a matter of coping with the stereotype in subsequent rotations and I guess that involves being gently and respectfully honest and letting the chips fall where they may. It's nice to know Augustine struggled, too. I feel like I'm in good company.

(Fair use of a copyrighted image of George Clooney as Dr. Doug Ross from "ER" claimed for the purpose of identifying the character in question with no commercial intent and in the absence of a similar, free image)